Independent pharmacies comprise a shrinking 35% of all retail pharmacies, predominantly serving patients in smaller cities and towns with 50,000 or fewer residents.1 Just as the retail pharmacy industry has changed in recent decades, these smaller communities are 97% more racially and ethnically diverse than they were in 1980.2 These demographic changes have increased the diversity of languages spoken in rural and non-metropolitan areas, in addition to the growth of the number of residents.
With a larger population of limited English proficiency (LEP) residents, a few state legislatures have passed laws requiring pharmacies to print prescription labels in languages other than English when requested by the patient. The major potential benefits of such laws are clear: fewer patient medication-related errors and greater adherence to treatment plans due to better understanding of instructions. The latter of which is especially important considering patients with LEP tend to have a lower medication adherence rate than English proficient patients.3
New York and California have had multi-lingual prescription label laws on the books for years. In 2020, Oregon enacted its law, SB 698, which requires pharmacies to print labels in 1 of 14 languages in addition to English at the patient’s request, which more than doubles California’s 5 required languages and New York’s 6. Oregon’s required languages include Spanish, Russian, Somali, Arabic, Chinese (Simplified), Vietnamese, Farsi, Korean, Romanian, Swahili, Burmese, Nepali, Amharic, and Pashto.4
Multi-lingual prescription label laws still raise the question as to why 6 or 14 languages are in use considering there are more than 350 languages spoken in households across the United States?5 Most pharmacies only need a few languages representing their local community, but those languages vary by location across the country and the less common languages represent a more difficult resource issue for many pharmacies. The capability to generate labels and patient education materials in a wider range of languages can cost-effectively attract and retain more patients to independent pharmacies, distinguishing them in their communities while increasing customer loyalty.
Existing Federal Rules for Language Access
While the labeling laws in New York, California, and Oregon are newer state laws, pharmacies in other states are also obligated to provide language services to LEP customers. Existing federal rules (EO 13166) already require meaningful access for persons with LEP based on enforcement of Title VI of the Civil Rights Act of 1964 “National Origin Discrimination Against Persons with Limited English Proficiency.” These rules are enforced by the Office of Civil Rights.
However, state labeling laws similar to Oregon’s add specificity for pharmacies, as determined by their state boards of pharmacy, as opposed to the broader federal requirements. Oregon’s law, for example, requires pharmacies to post signs informing patients with LEP that they are entitled to free, competent oral interpretation and translation services.
Oral Interpreting vs. Translation
In many smaller communities, prescribers and pharmacists usually rely on available bilingual staff, oral interpretation services, such as telephone interpreters, or family members to educate patients, but often do not provide written translation instructions for their medications. Oral instructions are more easily forgotten or misremembered, leading to potential medication-related errors and patient harm.
A study of Hispanic parents with LEP and limited health literacy indicated that they were more than twice as likely to make mistakes dosing liquid medications for their children.6 Likewise, patients with LEP had lower medication-related self-efficacy scores than patients with greater English proficiency, which may put them at greater risk for medication errors and lower adherence.7
Maintaining Workflow Efficiency
Access to easy-to-understand printed dosing instructions and educational materials can reduce such medication errors while improving patient self-efficacy. However, providing such medication instructions in the language preferred by the patient or caregiver should not cause significant operational and financial burden or disruptive manual processes for pharmacies.
Independent pharmacies need a low-cost offering from their pharmacy management and dispensing system vendors that automatically generates multilingual labels and education within their established workflows. Such systems should store the customer’s preferred language, automatically generate labels on repeat visits, and offer an increasing number of supported languages in the future.
The capability to capture preferred language is important because patients and caregivers with LEP are often embarrassed or intimidated to request such assistance at each visit. A survey of LEP Spanish-speaking adults found that “fear of disclosing limited English skills” was a major barrier to accessing needed care, and their LEP has led to miscommunication about medication changes.8 In an ideal situation, the documentation of the preferred language should be transmitted with the prescription from the provider and automatically entered in the system.
In addition to the patient’s preferred language on the label, pharmacies should offer simpler drug-specific information sheets, written at lower reading levels in the given language. Concise drug information sheets that incorporate the key basic information on proper use, adverse effects, and when they should contact their provider can reduce the overwhelming effect of the more comprehensive drug sheets currently used. A visual medication literacy aid, known as the Universal Medication Schedule (UMS), can improve adherence by helping patients schedule their medications at 4 times during the day—morning, noon, evening, and bedtime. This UMS format is being used by a growing number of retail pharmacies.
Additional safety features, such as visual illustration of syringes with proper dosing and pill images, can also prevent medication errors. Simple visual instructional elements combined with easy-to-understand text can boost understanding and benefit both LEP and low health literate English-speaking populations.9 Approximately 1 in 3 individuals in the United States are considered to be low health literate.10 The ability to provide such consumer-focused features and services demonstrates to patients that independent pharmacies are committed to being a central health care resource in each community.
Expanding Care Access and Loyalty
In 2019, there were 21,683 independent community pharmacies, down from 22,478 in 2014. Likewise, the average prescription volume was 57,414 per store in 2019, declining more than 1000 prescriptions since 2018.
Sustaining independent pharmacies in large and small communities will require these businesses to change based on how the market evolves. If their communities are becoming diverse, they should not wait for a new law requiring them to print labels in the languages representing their community.
Rather, independent pharmacies should be proactive and modernize their operations in anticipation of these changes to offer superior pharmaceutical care in their communities compared to their competitors, encouraging patient satisfaction and loyalty. Alliances representing community pharmacies, such as the National Community Pharmacists Association, can leverage their collective voices to push vendors for more consumer-friendly features.
By translating labels and education materials, pharmacies can, more importantly, improve their patients’ understanding of their prescription, including dosing and regimen schedules.11
Implementing such changes does not need to be difficult, which has been proven in a 2015 survey which looks at New York City pharmacies.12 Reliable translated content solutions that can be easily integrated with pharmacy management systems have emerged to make it easier and faster for independent pharmacies to not only comply with state and federal requirements but also to go beyond the law to better serve their patients and the community.
About the Author
Charles Lee, MD, is senior director of Clinical Knowledge for FDB (First Databank), which publishes and maintains drug databases for healthcare professionals that are used by the majority of the nation’s hospitals, physician practices, pharmacies, payers, and other health care industry segments.
1. National Community Pharmacists Association. NCPA Releases 2020 Digest Report. Published October 19, 2020. Accessed June 28, 2021. https://ncpa.org/newsroom/news-releases/2020/10/19/ncpa-releases-2020-digest-report.
2. Lee B, Farrell C. Is Ethnoracial Residential Integration on the Rise? Evidence from Metropolitan and Micropolitan America Since 1980. In: Lee B, Farrell C. Diversity and Disparities: America Enters a New Century. The Russell Sage Foundation. 2014: 415- 455. https://www.russellsage.org/sites/all/files/logan/logan_diversity_chapter13.pdf
3. Westberg SM, Sorensen TD. From Pharmacy-related health disparities experienced by non-english-speaking patients: impact of pharmaceutical care. Journal of the American Pharmacists Association. Jan-Feb 2005; 45(1):48-54. doi: 10.1331/1544345052843066.
4. 80th Oregon Legislative Assembly—2019 Regular Session. Senate Bill 698. https://olis.oregonlegislature.gov/liz/2019R1/Downloads/MeasureDocument/SB698/A-Engrossed. Published April 15, 2019. Accessed June 28, 2021.
5. 80th Oregon Legislative Assembly—2019 Regular Session. Senate Bill 698. https://olis.oregonlegislature.gov/liz/2019R1/Downloads/MeasureDocument/SB698/A-Engrossed. Published April 15, 2019. Accessed June 28, 2021.
6. Harris LM, Dreyer B, Mendelsohn A, et al. From Liquid Medication Dosing Errors by Hispanic Parents: Role of Health Literacy and English Proficiency. 2017 May-Jun; 17(4): 403–410. doi: 10.1016/j.acap.2016.10.001.
7. Zhang Y, Solomon C, Moreno G, et al. From Medication Related Self- efficacy among Linguistically Diverse Patients with Chronic Illnesses. Journal of Health Care for the Poor and Underserved. August 2018; pp. 1054-1068. doi: 10.1353/hpu.2018.0079.
8. Brooks K, Stifani B, Batlle R H, et al. From Patient Perspectives on the Need for and Barriers to Professional Medical Interpretation. Rhode Island Medical Journal. January 2016; 99(1): 30-33. ISSN 2327-2228.
9. HealthyPeople.gov. Health Literacy. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/health-literacy. Published 2020. Accessed June 28, 2021.
10. Center for Health Care Strategies. Health Literacy Fact Sheet. https://www.chcs.org/resource/health-literacy-fact-sheets/. Published October 2013. Accessed June 28, 2021.
11. Bailey S, Sarkar U, Chen A, Schillinger D, Wolf M. From Evaluation of Language Concordant, Patient-Centered Drug Label Instructions. Journal of General Internal Medicine. 2012 Dec; 27(12): 1707–1713. doi: 10.1007/s11606-012-2035-3.
12. Weiss L, Scherer M, Chantarat T, et al. From Assessing the Impact of Language Access Regulations on the Provision of Pharmacy Services. Journal of Urban Health. 2019 Aug; 96(4): 644–651. doi: 10.1007/s11524-018-0240-z.